Comparative Analysis of the Efficacy and Safety of Combined Pneumatic and Ultrasonic Lithotripsy in the Treatment of Patients with Staghorn Nephrolithiasis

Abstract

Urolithiasis is one of the most common disease encountered in the daily practice of a urologist. Depending on the severity of the course, patients with urolithiasis and, in particular, kidney stones, are often required to have the surgical treatment. The greater problem is deemed to be staghorn nephrolithiasis and the choice of the optimal surgical technique for the elimination of kidney stones.

The objective: to evaluate the efficacy and safety of the combined method of fragmentation of coral kidney stones in comparison with standard ultrasound lithotripsy.

Materials and methods. A total of 352 percutaneous nephrolithotripsies (PCNL) were performed: 187 (53,1%) – patients who were diagnosed with staghorn calculi. The age of the patients ranged from 26 to 66 (mean age 42,5 years). There were 89 men and 98 women. 78 (41.7%) patients had previously undergone surgical treatment (open surgery or PCNL) of kidney stones, in which recurrent staghorn stones were subsequently identified. Nine (4,8%) patients had bilateral coral calculi. The size of the stone varied from 3,5 to 11,0 cm. Their density ranged from 300 to 1500 Hounsfield units.

The most frequent complication of the underlying disease was chronic pyelonephritis – 145 (77,5%) patients. Hydronephrosis on the affected side was diagnosed in 98 (52,4%) patients. A combined pneumatic and ultrasonic lithotripter ShockPulse-SE from Olympus (Japan) was used for breaking kidney stones. We performed PCNL in a combined mode in 41 (21,9%) patients with staghorn nephrolithiasis.

Results. In the group of patients using combined pneumatic and ultrasonic lithotripsy, complete removal of the staghorn calculus was achieved in 97,6% of cases (in 40 of 41 patients), whereas in the opposite group, using an ultrasonic lithotripter only in 84,9% (in 124 of 146 patients). The duration of the PCNL operation using the ShockPulse-SE device was from 35 to 130 minutes, on average – 48±5 minutes. The duration of the surgical intervention using an ultrasound lithotripter is from 90 to 180 minutes, an average –105±7 minutes. Blood loss during PCNL using an ultrasonic lithotripter was 200–400 ml, whereas with the ShockPulse-SE apparatus – 100–200 ml. An exacerbation of pyelonephritis was noted in 7 patients (in two patients after PCNL in a combined mode and in five after PCNL using an ultrasonic lithotripter).

The mean length of patient hospitalization after surgery ranged from 4 to 10 days. At the same time, the average duration after PCNL using the combined ShockPulse-SE technique was 4±1 days, while after PCNL using an ultrasonic lithotripter it was 6±1 days.

Conclusions. The combined technique of lithotripsy with a combined probe for simultaneous pneumatic and ultrasound lithotripsy has shown better results in terms of safety and efficacy compared to using only an ultrasound lithotripter. Used for decades, ultrasound lithotripsy for staghorn stone PCNL is both effective and safe moreover it’s a traditional technique. Thus, in comparison with ultrasound lithotripsy, the combined technique showed a shorter operation time, with less blood loss, a shorter length of patient hospitalization and less pyelonephritis in the postoperative period, as a result of maintaining a lower intrarenal pressure gradient during the operation. At the same time, the cost of the procedure using a combined probe was estimated, which turned out to be higher than traditional ultrasound lithotripsy. The use of combined lithotripsy with simultaneous aspiration of stone fragments is an indisputable advantage of this kind of PCNL in patients with staghorn nephrolithiasis, which brings the effectiveness of this technique closer to 100%.